Required information Policy Number 054351278 Insured Jane Hellman Brandels Premium Due Quarterly $1,414.98 AMOUNT PAYABLE Maximum Benefit Limit, per covered person $2,000,000 Stated Deductible per covered person, per calendar year. $2,500 EMERGENCY ROOM DEDUCTIBLE (for each visit for liness to an emergency room when not directly ad the hospital) $50 Note: After satisfaction of the emergency room deductible, covered expenses are subject to any applicat deductible amounts and coinsurance provisions. PREFERRED PROVIDER COINSURANCE PERCENTAGE, per calendar year For covered expenses in excess of the applicable stated deductible, payer pays. 100% A. What type of health plan is described: HMO, PPO, or indemnity? PPO B. What is the annual premium? $ $U C. What is the annual deductible? $ 2,500